British Question Evidence Based Medicine

Publicerings år:  2000
Nummer: 2
When evaluating the reforms proposed by the government in Britain, several British scientists in the health field are questioning not only the reforms but also the concept of evidence based medicine (EBM). Understandably, British health workers are critical toward the new organizations governing the National Health Service (NHS) – the National Institute for Clinical Excellence (NICE) and the Commission for Health Improvement (CHI) – since nobody knows how these new organizations will be able to improve the NHS.

As an outsider, and not specifically dependent on British health services, it is disappointing to see many well-known English colleagues use the current situation to deflate the concept of evidence based medicine. Years ago, the Swedish medical community adopted the idea that health care should be based on the best available scientific evidence. The new concept of EBM does not seem to change this fundamental attitude. It is considered to be an extension of earlier practices.

It may be true that the advent of NICE and CHI can be considered a threat to clinical freedom. This, however, does not necessarily justify the broad criticism of EBM. John R Hampton questions the need for NICE, and specific guidelines from such an organization, as cardiologists know how to interpret the evidence from the many trials: “Does NICE have any better view of the ‘truth’ than cardiologists who are, after all, specialists in their field?”

What is evidence based medicine?
The entire EBM concept may seem to be another case of the emperor’s new clothes. Certainly, we have always aimed to follow the best scientific knowledge in Western medicine, and the concept of EBM may be only a new way of expressing what has been common practice for a long time. What is new, however, is the systematic way in which we search for, arrange, and present knowledge to the medical community. In Sweden, we view EBM as a systematic way to express reliable knowledge from the world literature for each type of advice – diagnostic, therapeutic, or prognostic – that you give a patient.

If you have access to results from randomized controlled trials, good. If you do not, there may be well-founded scientific results from other studies. If those are lacking, you may be able to find well-defined observational studies that will help solve the problem you want to address. EBM does not require decisions to be based on randomized controlled trials (RCT), only that you know exactly how good the evidence is in the contemporary literature. Furthermore, EBM does not necessarily imply the creation of guidelines, but may well be a good foundation for them.

Much of the reasoning behind the criticism aimed at EBM is based on a questionable interpretation of the concept. What evidence based medicine really stands for can certainly be discussed. Another issue concerns who within the medical community will benefit most from it. To assume that EBM will lead only to strict guidelines that will be enforced by governmental action is not what we want to see in the concept.

Another misunderstanding concerns who is in need of guidelines. Hampton argues that cardiologists know what they are doing and do not need help from a bureaucratic governmental organization. Most patients with cardiovascular disease are, however, not treated by cardiologists but by general practitioners who may need the advice offered by official guidelines.

Speaking from the experience of SBU, we are not certain that all specialists can interpret the results of all studies, even within their own fields. Many, if not most, published trials have deficiencies which must be compensated for. Perhaps this is better addressed by someone not directly involved with the field the trial covers. We are not in a position to consider whether there is a need for NICE or CHI since this is a purely British matter. The definition of evidence based medicine is of much greater importance, as this definition has bearing throughout the world. The discussion on the value of guidelines, and the organizations behind them, has been conducted in a way that suggests the authors may have gone overboard in their eagerness to denounce the bureaucracy of the NHS when they also reject the concept of evidence based medicine.

Lars Werkö

Miles A, Hampton JR, Hurwitz B (ed): NICE, CHI and the NHS Reforms Aesculapius Medical Press, London 2000.